Chevy Chase Nursing & Rehab Center
Facility I.D. Number: 0040592
Date of Survey: 02/05/2003
The facility shall notify the Department of any incident or accident which has or is likely to have a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department.
1) Notification shall be made by a phone call to the Regional office within 24 hours of each serious incident or accident. If the facility is unable to contact the Regional Office, notification shall be made by a phone call to the Departments toll-free complaint registry number.
2) A narrative summary of each serious accident or incident occurrence shall be sent to the Department within seven days of the occurrence.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care.
Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
The DON shall supervise and oversee the nursing services of the facility, including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psycho-social status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
Developing an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24-hour-a-day supervision of the door, a signal is not required.
These REQUIREMENTS are not met as evidenced by:
Based on observations, interviews and record review, the facility failed to supervise and protect one resident (R2) in the facility who eloped on 01/19/03, from approximately 8:30P.M. to 12:30A.M. on 01/20/03. R2 had previous documented elopement attempts and had also previously cut off his electronic monitoring device. The facility was not aware that this resident had left the facility that night until R2's family notified them that he had been found at his home. The facility failed to have staff at an unalarmed front entrance/exit door to monitor from 8P.M. to 10P.M. on 01/19/03.
Per record review, R2 has diagnoses that include Cognitive Disorder, Moderate to Severe Receptive and Expressive Aphasia, Cerebrovascular Accident, Hypertension, History of Alcohol and Substance Abuse. It was also documented in R2's hospital record dated 01/16/03, that he has "Impaired Safety Awareness ", and that he is a possible elopement since he is ambulatory and confused, and that he was on "1:1 nursing for
R2 was admitted at the facility on 01/16/03, and was discharged to Jackson Park Hospital on 01/26/03. During his 10-day stay at the facility, R2 had multiple elopement attempts on the following dates: 01/17/03, 01/19/03, 01/20/03, 01/22/03, 01/24/03, and 01/26/03 (2 attempts). R2 successfully was able to get out of the facility on 01/19/03, and on 01/26/03. On 01/26/03, a nurse followed him outside but then he fell, and could not pursue the resident further.
Per Z2 (R2's wife) on 01/20/03, at around 12:30P.M. R2 rang their doorbell wearing a yellow lady's winter jacket/parka , a pair of jeans, his imitation suede shoes and a hat. Z2 said that R2 was not wearing gloves, was shivering and said that he was cold and hungry. R2 added that he walked from the facility that night. Per E5 (11-7 Nursing Supervisor), she received a call from Z2 at around 11:30 P.M. of 01/19/03, that R2 had walked home. E5 said that she was just starting her shift and that no one knew that R2 left the facility that evening. According to E3 (7-3 nurse who worked on 3rd floor), she stayed over that evening of 01/19/03, and passed the evening medications to the residents on 3rd floor. E3 added that she left at around a quarter to 8P.M. and she last saw R2 at around 7:45P.M. in the 3rd floor day room. E3 added that E8 (3-11 nursing Supervisor) is suppose to take over as the 3rd floor nurse. When E8 was interviewed on 02/04/03, at around 9:35P.M., E8 said that on 01/19/03, no one told her that R2 was missing. E8 added that though she was the supervisor that evening, she was working on the 2nd floor and told the Certified Nurse Assistants (CNAs) on the 3rd floor to call her if something went wrong. E8 told the CNAs to do their visual rounds and no one told her R2 was missing. E8 added that there is no security between 8P.M. to 10P.M. at the front door. When E6 (3rd floor CNA) was interviewed on 02/05/03, E6 mentioned that she last saw R2 at around 8:30P.M. of 01/19/03, coming out of the day room. E6 added that she did her last round at around a quarter to 10P.M. but did not go inside R2's room because she thought that R2 was in his room's washroom since the water was running inside. Furthermore, E6 said that she did not hear any alarm go off that evening and was not aware that R2 has eloped from the facility. Per observation on 01/30/03, as long as the electronic device is in place and is attached to a resident, the alarm by the elevator sets off as soon as the resident comes near it. In R2's case however, he was able to cut it off without the staff's knowledge on 01/19/03. Per E3, when she came back on 01/20/03, they showed her R2's removed electronic device. Without the electronic device in place, a resident can go in the elevator and leave the 3rd floor unit undetected.
When Z1 (R2's attending physician) was interviewed on 02/04/03, Z1 explained that the reason why R2 is able to find his way home is because of his good remote memory which according to Z3 (Speech Therapist who evaluated R2) is common to residents who had Stroke or CVA like R2. Z1, who
examined R2 on 01/20/03, further added that even with a good remote memory, R2 is very confused, and that he is not safe to be out of the facility by himself. Z1 added that he did not order pass privileges for R2, did not advise it unless R2 is accompanied by his wife. Per Z2, R2 said that he walked home that night. Review of street map from the facility to R2's home indicated that the distance was approximately 7.6 miles. On 01/19/03, the temperature ranged from 6.8 degrees F to 30.2 degrees F. At around 9:45 P.M. of 01/19/03, the temperature was recorded at 30.2 degrees F.
E5 stated that when R2 was brought back to the facility on 01/20/03, he was not wearing the electronic monitoring device that Z1 ordered for him. Per E6 and E4 (7-3 nurses), and per R2's Nurses Notes dated 01/20/03, R2 was able and had previously removed his electronic monitoring device even before his successful elopement on 01/19/03. Review of R2's chart showed no evidence that the facility reassessed R2 and devised a safety and supervision plan after having knowledge that this resident continued to remove his alarm device and continued to attempt elopement. Per R2's Physician Order Sheet, R2's electronic monitoring device was discontinued on 01/20/03, without a full assessment of his elopement risk and without any substitute
plan in place to monitor this resident without using the alarm. R2 had a second elopement on 01/26/03. Review of R2's only documented Elopement Risk Assessment dated 01/16/03 showed that R2 is high risk for elopement, yet no elopement care plan was put in place until 01/21/03, (five days after R2's admission) even though the facility had placed an electronic monitoring device on this resident upon admission. R2 had already managed to elope from the facility on 01/19/03.
Facility failed to notify Public Health per E2 (Director of Nursing) of both incidents of R2's elopement because they did not consider that R2 had eloped from the facility. Per Z1's interview, resident's diagnosis and assessments, R2 is not safe outside of the facility because his remote memory remains intact after his CVA. R2 is very confused and was not safe to walk home in the middle of the night casually dressed and not supervised by staff. Furthermore per Z4's (psychiatrist) progress notes dated 01/20/03, R2 "was not able to answer questions correctly", "mumbles incoherently", and "he was not able to follow simple instructions," all necessary to communicate outside of the facility.